I,Name give the AmeriCorps Nonviolence KOPS Program and its fiscal agent, the Michigan Institute for Nonviolence Education (MINE), permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of the KOPS Program or MINE activities. I agree that the KOPS Program and MINE have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the KOPS/MINE’s missions. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release the KOPS / MINE and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.I have read and understood this consent and release.I give my consent to the KOPS/MINE to use my name and likeness to promote the KOPS program, its fiscal agent, and/or their activities.Signature Date MM slash DD slash YYYY Parent / Legal Guardian (if age 17) Date MM slash DD slash YYYY I do not give my consent to the KOPS/MINE to use my name and likeness to promote the KOPS program, its fiscal agent, and/or their activities.Signature Date MM slash DD slash YYYY Parent / Legal Guardian (if age 17) Date MM slash DD slash YYYY